What recourse, if any, do I have in dealing with this equipment charge from my podiatrist?September 9, 2011 6:49 PMSubscribe

About six weeks ago I went to a podiatrist for heel pain and was diagnosed with plantar fasciitis. I was given instructions for treatment along with a night splint that I've been wearing every night. Today, I received a bill from the podiatrist's office for the splint: Blue Cross has paid $80 of the $280 (!) charge, and the podiatrist's office is now putting me on the hook for the $200 balance. What recourse, if any, do I have in dealing with this charge?

Because this night splint is, quite frankly, a little on the shoddy and simplistic side (it's already falling apart in some areas), I decided to look it up on the web. I found the exact same model, by the exact same manufacturer, in the exact same size, on Amazon from several vendors in the $40 to $50 range. I am assuming that my podiatrist's office paid this much or less for it. I know doctors frequently get screwed by insurers and their prices can be kind of wacky in anticipation of getting less from the insurer, and I'm generally sympathetic to doctors in that scenario. But I also feel like taking the patient for a ride with a ridiculous markup like this is outrageous.

Since I discovered all of this after business hours, I won't have the chance to call and ask about this until Monday, but I want to make sure I approach it right. I assume I'm technically liable for the charge no matter what, but, have any of you had success in negotiating down a charge like this? (Or, preferably, negotiating it out of existence--I feel like since Blue Cross already paid them twice the market value of the item, I shouldn't be paying anything.) Assertiveness in these sorts of situations is not my strong point, so, any advice on how to handle this smoothly would be appreciated.

So you didn't ask how much it cost at the doctor's office and now, 6 weeks later, you want a discount? I went to the podiatrist 2 years ago for issues with my arches. I ended up having to buy orthotics from them. My first question was "how much are these little plastic things that go in my shoes- $60. Awesome, great deal /facetious.

Maybe next time ask how much something is and do your due diligence. As this wasn't an emergency, you could always go home and look around for something cheaper online and then call them up and say "hey, I want to buy those shin splints from you" if you decide to go with them.posted by TheBones at 7:06 PM on September 9, 2011 [1 favorite]

You really need to have a look at your plan's co-pays for medical devices. Every plan is different, and there's no way for anyone here to tell you if you were charged in accordance with your plan.posted by MissySedai at 7:07 PM on September 9, 2011

You might actually have more luck contacting your insurance company about this. Letting them know that they are being billed three times the market value for an item might motivate them to give your doctor's office a call. My mother had a sort of similar issue once (the doctor's office was in effect trying to bill her for something the Health Insurance company had already negotiated a price and paid for) and she contacted them about it. They called the doctor's office and took care of it. Can't hurt to try that route. In this particular instance the interests of your insurance company are aligned with yours.posted by katyggls at 7:08 PM on September 9, 2011 [3 favorites]

Realistically, you don't actually have "recourse," as you acknowledge. You just need to be prepared to give them a ring and explain your situation and ask them to work with you.

You don't really have to be aggressive here, and probably wouldn't gain anything from that. Draft up bullet points of your main points, which you've expressed here. They sell for $50 on Amazon; your insurer only covered $80; you feel like having to pay an additional $200 out of pocket is excessive and a hardship; is there anything they can do to work with you here.posted by J. Wilson at 7:08 PM on September 9, 2011 [1 favorite]

Agreed. The buck stops on your desk in terms of: 1. being aware of the cost of items and 2. knowing what your insurance coverage is. I don't believe you have much recourse other than to find a Dr. whom you feel isn't overcharging you.posted by tomswift at 7:09 PM on September 9, 2011

The amount that the office charges to an insurer is not what they expect to get as payment. That's one of the oddities of healthcare in this country. They never expected to get $280 for the thing, and they don't expect you to pay that either. You just need to do the same thing your insurance did and call to bargain with them on what the cost to you should be. Cost is very fluid in healthcare in the USA.posted by treehorn+bunny at 7:14 PM on September 9, 2011

I work for a surgeon and sometimes have control over who gets their money back if they cancel their (elective)surgery. My advice is - be SUPER nice, otherwise the person who you interact with over the phone will have zero motivation to plead your case to the doctor. If you are aggressive or insulting, she may actually be motivated to ask the doctor *not* to help you out in order to punish you for being a dick.posted by tatiana wishbone at 7:18 PM on September 9, 2011

I used to manage a dental office. The kind of negotiation that you are suggesting is very tricky to do well with an office. Patients (including yourself, at the moment) come at these conversations as though we are adversaries, the office is trying to screw them, and they want to pay nothing. That makes the staff and the doctor defensive. Defensive people are less likely to be generous in their negotiation.

You do not say that this is the bill for the whole visit, but I would guess that it might be. It's also possible that your office visit had a copay of, let's say $15 and your insurance pays another, let's say, $30 for a visit.

If that is the case, you have left any valuation of the doctor's time out of your equation, because $45 for what is at least a man hour of work is peanuts (seriously, the front office staff probably called you to confirm your appointment, the front office staff spent at least 10 minutes, and probably more preparing your claim, somebody cleaned the exam room between your visit and the next, somebody stocks those devices. I'll spare you the rest.) peanuts

On top of that, you ought to be considering other overhead. Rent, electricity, paperwork, office supplies, the generosity in their billing insurance for you instead of letting you fend for yourself on that front.

Additionally, your responsibility, as the patient is to ask about fees and be aware of your coverage before you receive care. Does that feel reasonable? Never, and I get that. But health insurance does not exist to prevent you from paying at the doctor. It exists to soften the blow. Bear in mind also, that insurance companies do not make money by paying claims. I would consider you lucky that they paid the $80 that they did.

In a very well run office, the doctor (believe it or not) doesn't have too much knowledge of the cost side of things. The doctor ought to be focusing on providing the best possible medical care. Patients need to be willing and ready to ask the money questions, and the doc needs to say, "I'm going to set you up with our financial blah-di-bla fancy sounding title Bob, who can review x y and z treatment options with you." Ideally there will be more than one option. But sometimes there just isn't. There are hundreds, of not thousands of services, tests, and products that doctors prescribe. Even the office staff relies on a computer program for pricing all but the most common of these.

Another thing to keep in mind, many (many) doctors see patients who otherwise could not afford medical care. This charity is, rightly or wrongly, subsidized in part by slightly higher costs for patients who have insurance or can otherwise pay. Because it sounds like the $200 is something you can manage, but would rahter not pay...and because I'm currently a person who does not get medical care because I'm underemployed I'm going to vote, suck it up and call with an honest and charitable approach to negotiating. You're genuinely surprised that blue cross paid so little, you did not understand the fee for the splint, would the office be able to help you out, and let you pay $100 for this fee, with the understanding that in future you will all be more proactive in discussing fees before service is rendered?" So yes, negotiate. But be kind about it, and start with the financial people, don't start with the doctor. Be appreciative of the help you've gotten from the device. Be nice about the warmth of the office staff, or whatever. Don't be a brown noser, but don't be a dick either.

Do not, please, do not bring up the online differential in cost. The online folks can ship you a splint for $40 because they have the warehouse space (which is cheaper than office space) to buy 6 cases at a deep discount. That warehouse is probably in the middle of nowhere, making rent even cheaper. They have very little overhead, they aren't doctors, and they don't know or care if the splint you're ordering is the right splint. If you "just ordered the splint online" you could have caused yourself more harm than good. That, right there, is worth orders of magnitude more than $200. The doc can keep maybe 2 of any given thing in stock, and they're all jumbled into a tiny space, so someone has to search for them.

(Funny story about doctor billing. I once got a nosebleed in my allergist's office. those were the days! being able to see my allergist! In addition to the regular office-y stuff we were scheduled for that day, they billed for "stopping the nosebleed." $300. You know how they "stopped the nosebleed?" They used some tweezers to put some gauze up my nose! Thankfully, part of what had driven me into the arms of this doctor was the nosebleeds. All the goddamned time with the nosebleeds. And nobody ever believed how bad they were unless they witnessed. So this doc got to see, firsthand, the carnage. But her edification was billed at $300, nevertheless.

As far as this :...trying to bill her for something the Health Insurance company had already negotiated a price and paid for...goes, no, that's not always how insurance works. The insurance company pays the Usual, Customary and Reasonable and the customer is usually contractually on the hook for the rest. Some insurance companies do negotiate the max that a patient can pay for a list of particular services. But not all of them.posted by bilabial at 7:18 PM on September 9, 2011 [7 favorites]

Did you look at your insurance Explanation of Benefits statement? It would normally show how much they were billed, how much they paid, and how much is your responsibility. If you don't get them in the mail, look at your account online and see if you can look at it.posted by cabingirl at 7:22 PM on September 9, 2011

AskMe always seems to respond this way to this kind of question: "You should have asked, it is your fault, you should feel bad for not bringing it up."

But that runs totally, totally counter to my real-life experience trying to price out healthcare. In my experience, when you ask a doctor (or a dentist) how much things will cost, they have no idea. Clinics that focus on poor people are better about this, but if you're at a middle-class office that mostly deals with insured patients, good luck.

OP: you may have some luck talking to the office manager or biller and calmly explaining that if you had known how much this was going to cost you would have said no, and it's a financial hardship to be on the hook for this much, can they cut you a deal. (I completely fail to see how this is somehow uncharitable of you.) That would be my first stop before dealing with the insurance company.posted by thehmsbeagle at 7:58 PM on September 9, 2011 [6 favorites]

First off, yes you should have asked about the price of this. Most offices know what they charge insurance companies for specific items. If the price they tell you is really high, tell them you want to wait on it. (Yes the price is different from the allowed amount, but it'll give a ball park range)

Check your EOB, find out what the insurance company states is your portion, this is especially important if your doctor's office is in network or not. Call your insurance company and have them explain why they paid what they did if you don't understand the EOB.

Please don't demand a discount or say you could get it cheaper online. This won't help your case. Office staff will not want to help you if you act like a fool. It really is the responsibility of the patient to know their benefits. Ask for a discount and they may come down, but be polite about it. Generally, the best way I've seen to get around the bills, is to find a way to get the insurance company to either pay more or lessen your responsibility.posted by Attackpanda at 8:26 PM on September 9, 2011

Check your actual policy to see how much BCBS is supposed to pay for medical devices. I and family members have had several (more than should have happened) claims where BCBS failed to pay what they were supposed to, or refused to pay altogether. The doctors office would have to resubmit the claim to get it all paid. So they either have shoddy data entry/processing or a habit of trying to get away with underpaying.

While you're at it, check to see what the allowed billable amount is. Sometimes that amount is all the doctor can charge to you (depends on how the contract is written between the insurance and the doctor).

The other thing to check is if the visit was billed correctly. Maybe the whole $280 should have been the office fee, but got coded as the splint, and BCBS pays less on splints than they do for office visits. So check all of the paperwork before you call anyone...you want to have all the correct information if you try to address it with the doctor's office.posted by MultiFaceted at 11:35 PM on September 9, 2011

Do pursue this with your insurance company. If the podiatrist you went to was in your insurance company's network, this may be illegitimate balance billing.posted by Lexica at 9:05 AM on September 10, 2011

I would encourage you to find out if the podiatrist accepts assignment. In Michigan any medical provider that is on BlueCross/Blue Shield's preferred provider list has to accept assignment. This means that even though they may charge whatever they choose to charge, the patient has to pay only the difference between the BC/BS payment and the BC/BS allowed charge for the service. The provider has to absorb the difference. If the patient isn't aware of this they may pay more than they absolutely have to.posted by WeaverRose at 10:43 AM on September 10, 2011

It's your responsibility to know how your insurance works, and to know if a health care provider is affiliated with your insurance. I have some variety of managed care, and have to get a referral. If the doc is 'in-network,' I pay a negotiated amount. If the doc in not 'in-network,' my insurance pays an amount based on the contract with my employer, and I pay the rest. It requires reading a lot of insurance documents, and is a pain.

You likely have a deductible - an amount you have to pay every year before the insurance company pays anything at all.

In your case, I'd call and ask your insurance company to explain. Then I'd call and try to negotiate a deal with the doctor's office. They may be willing to negotiate the fee; worth a shot.posted by theora55 at 1:19 PM on September 10, 2011

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